Traumatic Encephalocele Research Articles

Traumatic encephalocele in the nasal cavity after 6 years of trauma: a case report

BackgroundEncephalocele refers to protrusion of the meninges and brain tissue through a skull bone defect. It results from congenital, traumatic, neoplastic, or spontaneous reasons. Traumatic encephalocele occurs because of the posttraumatic fracture of the skull bone or iatrogenic causes. The manifestations vary a lot, such as rhinorrhea, seizures, headaches, and focal neurological deficits.Case presentationA 20-year-old Syrian male presented to our department with the complaint of clear cerebrospinal fluid drainage from his right nostril, which started 6 years ago after a head trauma, moderate headache, and episodes of tonic–clonic seizures without any response to medical treatment. Then, 2 months ago, the patient had meningoencephalitis, so he was admitted to the intensive care unit and treated for a month until he was cured. The patient underwent radiological investigations, which showed that he had a base fracture with an encephalocele in the nasal cavity. The brain tissues with the meninges herniated through the skull base fracture with a significant expansion of the subarachnoid spaces in the right hemisphere. He was advised to undergo surgical repair at that time, but he refused the surgery. During this visit, surgery was indicated. The surgery was done by a specialist who returned the herniated brain tissues to their normal location, repaired the meninges, and reconstructed the skull base with bone cement and bio-glue. The patient’s recovery after the surgery was uneventful.ConclusionTraumatic encephalocele is a rare and unexpected complication of trauma, but we should keep it in mind when the patient comes with head trauma because of its life-threatening consequences. This complication can happen after years of trauma if the patient refuses treatment, therefore, we must educate patients about the dangerous results of neglecting cerebrospinal fluid leakage and skull fractures.

Post Traumatic Intra Orbital Encephalocele, a Rare Cause of Pulsating Orbit: Case Report

Orbital trauma is a prevalent condition in clinical practice, particularly in situations of head trauma. Orbital roof fractures following a blunt trauma are an uncommon consequence of trauma. Traumatic encephaloceles in the orbital cavity are much more uncommon, with only a few examples reported to date. Early detection and therapy of raised intraorbital pressure can avoid irreparable optic nerve injury. In trauma patients with concomitant orbital injuries, orbital computed tomography (CT) with thin axial and coronal slices is beneficial. Decompression of the orbital roof is the most important stage in surgical therapy and should be done in all cases. We report the case of an adult with a post-traumatic orbital encephalocele. A few hours after a road traffic accident with head injury, the patient developed progressive pulsatile enophtalmosis. Computed tomography revealed multiple fractures of the orbital rim with herniation of the left frontal lobe into the orbit.

Natural History of Traumatic Encephaloceles: A Systematic Literature Review.

Encephaloceles rarely develop following traumatic skull fractures. Given their low incidence, the clinical presentations and management strategies of these lesions are confined to case reports and limited case series. A systematic literature review was performed using PubMed, Ovid, and Web of Science databases to identify relevant articles using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 37 articles met inclusion criteria, including the case presented herein. These articles reported 52 traumatic encephaloceles. Mean patient age was 25.3 years (range 6mo-66y) with a male predominance (63%, 33/52). The most common bony defects resulting in encephalocele formation were the orbital roof (52%, 27/52), ethmoid (35%, 18/52), and sphenoid (10%, 5/52). Mean time from traumatic injury to initial presentation was 21.3 months (range 0d-36y) with a bimodal distribution split between immediately following the traumatic injury (57%, 26/46) or in a delayed manner (43%, 20/46). Common presentations of orbital roof, frontonasal, and temporal bone encephaloceles were exophthalmos (85%, 23/27), cerebrospinal fluid rhinorrhea (71%, 17/24), and hearing loss (100%, 4/4), respectively. Operative approach, repair technique, and materials used for encephalocele reduction were highly variable. Surgical intervention afforded definitive symptomatic improvement or resolution in the majority of cases (89%, 42/47). Clinical outcomes did not differ between orbital, frontonasal, or temporal bone encephaloceles ( P =0.438). Traumatic encephaloceles are a rare entity with diverse presenting symptomatology dependent upon the location of fracture dehiscence. Surgical intervention affords symptomatic improvement in the majority of cases irrespective of encephalocele location, time to presentation, or operative approach.

Pediatric nonoperative skull fractures: delayed complications and factors associated with clinic and imaging utilization.

Skull fractures represent a common source of morbidity in the pediatric trauma population. This study characterizes the type of follow-up that these patients receive and discusses predictive factors for follow-up. The authors reviewed cases of nonoperative pediatric skull fractures at a single academic hospital between 2007 and 2017. Clinical patient and radiological fractures were recorded. Recommended neurosurgical follow-up, follow-up appointments, imaging studies, and fracture-related complications were recorded. Statistical analyses were performed to identify predictors for outpatient follow-up and imaging. The study included 414 patients, whose mean age was 5.2 years; 37.2% were female, and the median length of stay was 1 day (IQR 0.9-4 days). During 438 clinic visits and a median follow-up period of 8 weeks (IQR 4-12, range 1-144 weeks), 231 imaging studies were obtained, mostly head CT scans (55%). A total of 283 patients were given recommendations to attend follow-up in the clinic, and 86% were seen. Only 12 complications were detected, including 7 growing skull fractures, 2 traumatic encephaloceles, and 3 cases of hearing loss. Primary care physician (PCP) status and insurance status were associated with a recommendation of follow-up, actual follow-up compliance, and the decision to order outpatient imaging in patients both with and without intracranial hemorrhage. PCP status remained an independent predictor in each of these analyses. Follow-up compliance was not associated with a patient's distance from home. Among patients without intracranial hemorrhage, a follow-up recommendation and actual follow-up compliance were associated with pneumocephalus and other polytraumatic injuries, and outpatient imaging was associated with a bilateral fracture. No complications were found in patients with linear fractures above the skull base in those without an intracranial hemorrhage. Pediatric nonoperative skull fractures drive a large expenditure of clinic and imaging resources to detect a relatively small profile of complications. Understanding the factors underlying the decision for clinic follow-up and additional imaging can decrease future costs, resource utilization, and radiation exposure. Factors related to injury severity and socioeconomic indicators were associated with outpatient imaging, the decision to follow up patients in the clinic, and patients' subsequent attendance. Socioeconomic status (PCP and insurance) may affect access to appropriate neurosurgical follow-up and deserves future research attention. Patients with no intracranial hemorrhage and with a linear fracture above the skull base do not appear to be at risk for delayed complications and could be candidates for reduced follow-up and imaging.

Interdisciplinary Management of Minimally Displaced Orbital Roof Fractures: Delayed Pulsatile Exophthalmos and Orbital Encephalocele.

Traumatic orbital roof fractures are rare and are managed nonoperatively in most cases. They are typically associated with severe mechanisms of injury and may be associated with significant neurologic or ophthalmologic compromise including traumatic brain injury and vision loss. Rarely, traumatic encephalocele or pulsatile exophthalmos may be present at the time of injury or develop in delayed fashion, necessitating close observation of these patients. In this article, we describe two patients with minimally displaced blow-in type orbital roof fractures that were later complicated by orbital encephalocele and pulsatile exophthalmos, prompting urgent surgical intervention. We also suggest a management algorithm for adult patients with orbital roof fractures, emphasizing careful observation and interdisciplinary management involving plastic surgery, neurosurgery, and ophthalmology.

Traumatic orbital encephalocele in an infant: using the fracture line to our advantage

Dear Editor, Traumatic encephalocele secondary to orbital roof fracture, though uncommon, has been reported in the past [3]. These cases warrant early intervention due to progressive proptosis and possible optic nerve compression due to raised intraorbital pressure. Apart from watertight dural closure, restoration of orbital contours is equally important to prevent post operative enophthalmos and transmitted pulsations [5]. Frontal craniotomy with repair of the dural defect and bony reconstruction with mesh is a standard procedure described in literature so far [2]. However, it is not desirable to use mesh in an infant. We describe here a unique method using the fracture line as one of the edges of the craniotomy to minimize bone loss, thereby achieving good cosmetic outcome without compromising the surgical exposure. A 6-month-old child presented with head injury due to a fall from a 20-ft height. Initially the child was unresponsive with GCS 4 and was put on mechanical ventilation. The immediate post-injury CT scan showed left-sided frontal contusion associated with frontobasal fracture extending across the orbital roof longitudinally, reaching just short of the optic canal (Fig. 1A, B). The child gradually improved. However, 3 weeks later, parents noticed progressive proptosis and increasing conjunctival edema of the left eye. Reconstructed CT and MRI showed herniation of brain matter into the left orbit through that fracture line (Fig. 1C-J). He was operated on through a curvilinear incision behind the hair line. Frontoorbital craniotomy was performed using the fracture line of the orbital roof and frontal bone as edges of the craniotomy (monobloc frontoorbital craniotomy). The lateral wall of the orbit was cut using a saw to reach up to the temporal base from where it was connected to the remaining craniotomy. This gave access to both the orbital and intracranial contents without the need to remove additional parts of the orbital roof. The underlying dural defect was completely delineated. Herniated brain parenchyma was resected, and a watertight dural closure was done. The bone flap was replaced in its normal anatomical position. A good cosmetic outcome was achieved. Proptosis reduced and there was no enophthalmos after a follow-up at 2 months (Fig. 1K-Q). However, a long-term follow-up is required, as recurrence is possible. Post-traumatic orbital encephalocele is rare among all the varieties of growing skull fractures. The mechanism of injury may be attributable to the under-developed frontal sinus, which is unable to dissipate the pressure over the orbital rim in patients below the age of 7 years [1]. The brain parenchyma may herniate through the underlying dural defect, resulting in orbital encephalocele. The usual clinical presentations are pulsatile exophthalmos, diplopia, lid swelling, and orbital asymmetry. The optic nerve is at risk due to raised intra-orbital pressure, and thus, immediate intervention is warranted in cases of traumatic orbital encephalocele [1, 4]. In all cases described to date, the herniated brain parenchyma into the orbit was accessed through a frontal craniotomy followed by nibbling of the orbital roof or removal of its fractured fragments [2]. Though the dural repair was very well achieved by this, the bone loss is likely to result in enophthalmos and feelings of transmitted pulsations in the orbit. A mesh repair S. K. Sahoo : P. S. Salunke (*) Department of Neurosurgery, PGIMER, Sector 12, Chandigarh 1600l2, India e-mail: drpravin_salunke@yahoo.co.uk

Acute traumatic orbital encephalocele: A case report with review of literature

Orbital roof fractures after a blunt injury are an uncommon complication of trauma. Traumatic encephaloceles in the orbital cavity are even rarer, with only 15 cases published till date. Raised intraorbital pressure leading to irreversible damage to the optic nerve can be prevented by early diagnosis and management. Orbital computed tomography (CT) with thin axial and coronal sections is helpful in trauma patients with a concurrent orbital trauma. Decompression of the orbital roof is the key step in surgical treatment and should be performed in every case. Repairing the orbital roof has to be performed to avoid transmission of variation in the intracranial pressure to the orbit. We present a case of traumatic orbital encephalocele who underwent surgical treatment via a frontobasal approach with evacuation of the contused herniated brain and reconstruction of the orbital roof using temporalis fascia which is readily available in contrast to costly materials like titanium mesh, screws, bone powder, fibrin glue, and so on, which are not easily available in every hospital. Rapid resolution of proptosis and visual symptoms along with excellent cosmetic outcome was seen at follow-ups after three and nine months. We emphasize the early diagnosis of this rare condition and also emergency treatment to prevent permanent visual loss as well as to achieve good cosmetic results.

Titanium Mesh Reconstruction of Orbital Roof Fracture with Traumatic Encephalocele: A Case Report and Review of Literature

Orbital roof fractures are rare. Traumatic encephaloceles in the orbital cavity are even rarer, with only 21 cases published to date. Orbital roof fractures are generally encountered in males between 20 and 40 years of age following automobile collision. We report a case of an orbital roof fracture with traumatic encephalocele into the left orbit. Early diagnosis and treatment are very important because the raised intraorbital pressure may irreversibly damage the optic nerve. Computed tomography with 3-D reconstruction, the imaging modality of choice, showed the displaced fracture fragment deep into the orbit. Reconstruction of the orbital roof should be performed in every case. We used an extracranial approach to elevate the fracture with titanium mesh to stabilize the fragment. The cosmetic results were excellent but delay in treatment was responsible for delayed recovery of vision. The case report is followed by a brief overview of orbital roof fractures including pertinent review of literature.

Endoscopic Reconstruction of the Middle Cranial Fossa Through a Subtemporal Keyhole Using a Pedicled Deep Temporal Fascial Flap

Reconstruction of the skull base is essential to prevent postoperative leakage of cerebrospinal fluid (CSF). However, a reliable method of reconstructing the middle cranial fossa via a subtemporal keyhole is not available. To determine whether less invasive reconstruction of the middle cranial fossa under endoscopic guidance with a pedicled deep temporal fascia approach via a subtemporal keyhole is feasible and useful. The middle cranial fossa in 4 fresh cadaver heads was reconstructed with a 4-mm 0° rigid endoscope. A subtemporal skin incision (subtemporal incision) was followed by 2 small skin incisions (temporal line incisions) made on the superior temporal line. The endoscope was inserted through the temporal line incisions, and then the deep temporal fascia was separated from the superficial temporal fascia and temporal muscle under endoscopic view. A pedicled flap was harvested from the subtemporal incision and applied to the middle cranial fossa after subtemporal keyhole craniotomy. The pedicled deep temporal fascial flap was flexible, long, and large enough to overlay skull base defects. This purely endoscopic technique using a pedicled deep temporal fascial flap provided reliable reconstruction of the middle cranial fossa through a subtemporal keyhole. This technique would also be applicable in preventing CSF leakage or treating traumatic, acquired nontraumatic, or congenital encephalocele in the middle cranial fossa.

Endoscopic treatment of traumatic basal encephaloceles: a report of 8 cases

Basal encephaloceles are rare entities that can present as congenital diseases; however, traumatic lesions due to head injuries or iatrogenic causes have been described in the literature. In this study the authors aimed to define placement techniques for free grafts in repairing traumatic basal encephaloceles and to describe the long-term effectiveness of endoscopic treatment. Between September 1997 and December 2006, 8 patients with traumatic encephaloceles underwent endoscopic surgery. A free graft following an underlay (2 cribriform plate and 4 ethmoid fovea defects) or obliteration (2 sphenoid defects) procedure was used as the repair material. All traumatic basal encephaloceles with the associated skull base defects and cerebrospinal fluid (CSF) leakage were successfully treated via the endoscopic approach. There were no major complications or recurrence of meningitis or leakage of CSF encountered after an average follow-up of 77 months. Long-term follow-up results demonstrated that endoscopic surgery was suitable for the treatment of traumatic basal encephaloceles. The underlay procedure is more appropriate than the overlay procedure in repairing large defects of the anterior skull base. Meticulous manipulations of the endoscope following precise autograft placement are mandatory for the successful repair of traumatic basal encephaloceles.

Encéphalocèle intraorbitaire post-traumatique chez un adulte : à propos d’un cas

Orbital roof fractures after head injury is rare. Traumatic encephaloceles in the orbital cavity are even rarer, with only 24 cases published to date. We report the case of an adult with a post-traumatic orbital encephalocele. One day after a road traffic accident with head injury, the patient developed progressive pulsatile proptosis. Computed tomography and magnetic resonance imaging revealed an isolated blow-in fracture of the orbital roof with herniation of the left frontal lobe into the orbit. Neurosurgery to repair the orbital defect led to full recovery.

A report of two ‘traumatic encephaloceles’; an unrecognized entity

Purpose: An unusual complication following severe head trauma in two infants is described.Method: ‘Acute traumatic encephalocele’ or ‘extracalvarial herniation’ is presented as an entity, different from ‘growing skull fracture’.Results: The acuteness of presentation and non-progressive calvarial fracture aperture, along with increasing size of herniated contents is the hall-mark of such pathology.Conclusion: Repair of dural defect with a patch after excision of gliosed brain provides satisfactory outcome.

Management of Cerebral Vascular Structures during Endoscopic Treatment of Encephaloceles: A Clinical Report

Otolaryngologists are increasingly being called upon to treat patients with cerebrospinal fluid leak and encephaloceles. The endoscopic approach to the skull base through the nose and paranasal sinuses has proven effective and is well tolerated by patients. With its more widespread and frequent use, unusual cases and potential complications are becoming more apparent. Treatment of two clinical cases in which a cerebral vascular structure was encountered during endoscopic treatment of an encephalocele is presented, and the condition is reviewed. Two patients presented after a skull base injury that occurred during endoscopic sinus surgery. In each case the initial treating surgeon attempted endoscopic repair of a cerebrospinal fluid leak, but the repair failed and the leak persisted. Upon referral to the author, in each case, a traumatic encephalocele with an active leak was apparent, and during repair a cerebral vessel was encountered. It appeared that the vessel had been "pulled down" into the skull base defect with the encephalocele's migration into the sinonasal cavity. This unusual clinical condition is discussed along with the potential complications that can result from it. Otolaryngologists who treat encephaloceles should be aware of the possibility of encountering a cerebral vessel and should understand the potential complications and management options.

Traumatic encephalocele related to orbital roof fractures: report of six cases and literature review

BACKGROUND Orbital roof fractures after blunt injury are rare. Traumatic encephaloceles in the orbital cavity are even rarer, with only 15 cases published to date. METHODS The clinical, radiological, and surgical findings of 6 cases of traumatic encephalocele treated at our institution from June 1998 to January 2000 are presented. They are also compared with previously published series. RESULTS In contrast to other published cases, 5 out of 6 patients in our series were adults. The most common cause of trauma was road traffic accident. Ecchymosis and preoperative exophthalmos/proptosis were frequent. In all of our patients a coronal CT scan (3 mm increments with bone windows) was obtained. It demonstrated the extension of the orbital roof fractures and a possible encephalocele in 4 cases. Associated frontal brain contusions were seen in 5 cases. An MRI was performed in 3 patients (and only in 2 previously published cases); it showed the extension of the brain herniation into the orbital cavity. Surgical treatment via a fronto-basal approach with evacuation of the contused herniated brain tissue and orbital roof reconstruction was performed. The outcome at 6 months was good recovery in five patients with one patient still in a persistent vegetative state. Postoperatively the ocular disturbances improved in 5 cases. A review of the other published cases confirmed recovery of normal ocular function in the vast majority of the cases. CONCLUSIONS Whenever orbital roof fractures associated with frontal contusions are identified in an acute brain injured patient, an orbital encephalocele should be suspected. In our opinion MRI is the investigation of choice in such patients. If the encephalocele is confirmed, a surgical approach via the subfrontal route is indicated with resection of herniated contused brain tissue, dural closure, and orbital roof reconstruction. Good results in regard to the orbital symptoms (mainly exophthalmos) can be expected.

Supraorbital Roof Fractures

Supraorbital roof fractures are uncommon. The incidence has been quoted at between 1 and 5%. We believed that the incidence and morbidity of supraorbital roof fractures were actually higher. The charts of 621 inpatients with facial fractures between September 1993 and September 1995 were retrospectively reviewed. Parameters included patient characteristics; mechanism of injury; fracture characteristics; associated clinical, computed tomography, and operative findings; presence of associated skull and frontal sinus fractures; and complication rates. Fifty-eight patients (9.3%) had supraorbital roof fractures, making this one of the largest series. The average age was 31 years and the predominant mechanism of injury was motor vehicle accidents. Sixty-nine percent of the patients had associated skull fractures and 54% had frontal sinus fractures. Thirty-one of the cases were open and 32 cases were treated operatively. Dural tears were present in 14 patients, traumatic encephalocele in 3, proptosis in 6, pulsatile proptosis in 3, orbital apex syndrome in 1, persistent cerebrospinal fluid leak in 3, and meningitis in 5. A majority of the patients had associated intracranial bleeds. The incidence and morbidity of supraorbital roof fractures are much higher than previously thought. The treatment of cases should be individualized, taking into account displacement, association with skull and frontal sinus fractures, dural tears, and intracranial hemorrhage.

Paranasal sinus hemorrhage: evaluation with MR imaging.

Computed tomography (CT) and magnetic resonance (MR) imaging were performed in ten patients with paranasal sinus hemorrhage after trauma. Acute or subacute hemorrhage was detected on MR images by using T1- and T2-weighted imaging to identify the chemical state of the blood and to differentiate blood from mucosal thickening and sinus effusion. Surgical proof of intrasinus hemorrhage was obtained in only two cases. Displaced fractures, associated cerebral contusions, and traumatic encephalocele were well shown on MR imaging. Nondisplaced and minimally displaced fractures were better evaluated with CT.